PATH To Care Service Request Form

PATH To Care

Service Request Form

care.berkeley.edu

Please do not use this form for advocacy services

For direct services for survivors and support persons please call

510-642-1988 or email ptcadvocates@berkeley.edu

Name*

Email*

Optional: Additional Contact Email(s)

Contacts listed here will be included in email communications regarding this request.

How did you hear about PATH To Care? *

What is your organization or department name?*

Request Type*

Please do not use this form for advocacy services. For direct services for survivors and support persons please call 510-642-1988 or email ptcadvocates@berkeley.edu

Select

Is this a mandatory, voluntary, or sanctioned request?*

Mandatory: Mandatory: if there is a policy or requirement in place by NCAA, PHC, IFC, CalGreeks, etc. to complete SVSH programming

Sanctioned: if you have been directed to complete SVSH programming as part of an agreement to redress a harm

Voluntary: RSOs, decals, or if not mandatory or sanctioned as described above

Select

Do you want an Undergraduate Peer Educator or a Professional Staff Member to present the workshop?*

Workshops for undergraduate students will be facilitated by PTC's Peer Educators unless there is a specific need otherwise.

Select

Peer Ed - Workshop Selection*

Select

Workshop/Presentation Type*

You may select more than one content area.

Select

Consultation Area*

You may select more than one area.

Select

Consultation Focus*

You may select more than one focus.

Select

Toolkit Type*

You may select more than one type.

Select

Please include the class / DeCal name in the Other box below.

Other (please specify):*

Please briefly describe your request*

Please provide any additional information about your request, such as

Title of an event
Location (remote/in-person)
Your goals for this service
Event URL
Links to relevant documents
Whether the service is for responsible employees
Whether the request is to help address an incident of SVSH that has occurred. Please do not disclose details in this form for confidentiality purposes.

Providing this information helps with expediting your request.

Group Size / Number of Attendees*

Estimated number of attendees

Dates and Times*

Please share at least 2 preferred dates for the service, including the start and end times below.

Accommodations*

Please include any accommodation requests. If none, please put N/A.

Examples: CART, ASL, AV, Captions

Send me a copy of my responses

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